LAX03LA212

NTSB accident investigation · Hughes 369D · Kualapuu, HI · June 26, 2003

Accident · Serious injuriesLimited investigationFinal report
Date
June 26, 2003, 13:15 local (23:15 UTC)
Place
Kualapuu, HI
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N633WAHughes 369D
Weather
Visual (VMC) · Day
Status
Completed · report December 28, 2004
Report
Approved by Office Director
Parties
Rolls-Royce, Federal Aviation Administration, Standard Aero Ltd., Windward Aviation
FAA report
20030626018849A
Case key
57333

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the total loss of engine power resulting from a fatigue failure of the 3rd stage turbine wheel airfoils. The reason for the airfoil's fatigue failure could not be determined.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfManeuvering
Turbine assembly,turbine blade - fatigueCause
Turbine assembly,turbine blade - failure,totalCause
Forced landingEmergency descent/landing
Autorotation - performedPilot in command
Hard landingEmergency descent/landing
Proper descent rate - excessive

Analysis

The pilot made a hard landing in the single-engine helicopter after experiencing a loss of engine power at 40 knots and 150 feet agl. The pilot was conducting fire suppression operations and had maneuvered the helicopter over a pond to pickup water. He heard a loud bang and looked over his shoulder to observe white smoke coming from the engine exhaust. The pilot entered an autorotation and began a flare at 50 feet agl with a high rate of descent. The helicopter impacted the ground and a fire ignited. The engine accumulated approximately 1,043 hours since undergoing a modification to its turbine section (approximately 707 hours short of its recommended overhaul time). The modification was part of a commercial engine bulletin, which converted the engines to obtain better performance "from the improved power turbine air flow characteristics." The conversion included a replacement of the 3rd and 4th stage turbine nozzles and wheels. A post-accident examination of the engine revealed the airfoils on the 3rd stage wheel failed as a result of fatigue cracking that originated at the airfoil's trailing edge and progressed toward the leading edge of the blades. All of the 3rd stage airfoils displayed some form of cracking near the airfoil roots at their trailing edges. A number of the cracks were attributed to fatigue propagation; however, some were attributed to overload. The 3rd stage turbine wheel and airfoils met the manufacturer's specifications and no material flaws or defects were noted at the fatigue cracking origins. The reason for the fatigue cracking and subsequent failures could not be determined.

Factual narrative

History of flight

On June 26, 2003, at 1315 Hawaiian standard time, a Hughes 369D single-engine helicopter, N633WA, was substantially damaged during an autorotational landing following a loss of engine power while maneuvering near Kualapuu, Hawaii. The commercial helicopter pilot, the sole occupant, sustained serious injuries. The helicopter was registered to, and operated by, Windward Aviation Inc., Kahului, Hawaii, under the provisions of CFR Part 133, external load operations. Visual meteorological conditions prevailed at the time of the accident and a flight plan had not been filed. The local fire fighting flight originated from the Molokai Airport, near Kualapuu, approximately 1300.

According to the operator, and the pilot's written statement, the helicopter was utilized to suppress fire by dumping water from an external bucket. The pilot was maneuvering the helicopter over a pond in order to pick up water at 150 feet above ground level (agl) and 40 knots, when he heard a loud bang. He looked outside over his left shoulder and observed white smoke coming from the engine exhaust and noted a loss of engine power. The pilot lowered the collective and began an autorotation; however, with the low airspeed and altitude, he "could not properly flare." He began his flare at 50 feet agl with a "high rate of descent." The helicopter impacted the ground, and after landing, the pilot rolled off the throttle, pulled the rotor brake, and exited the aircraft after he heard a crackling sound.

A fire ignited around the helicopter burning the aft end of the fuselage and forward section of the tail boom.

Personnel information

The commercial helicopter pilot accumulated a total of 11,568 hours in helicopters, of which 8,055 hours were logged in the accident helicopter make and model. The pilot also held a flight instructor certificate for helicopters. He was issued a second-class medical certificate on June 6, 2003, with a limitation to wear corrective lenses. His last flight review took place on March 7, 2003, in the same make and model as the accident helicopter.

Aircraft information

The accident helicopter was equipped with an Allison 250-C20B turboshaft engine (serial number CAE 830351). It should be noted that manufacturing responsibilities for the Allison 250 engines were acquired by Rolls-Royce, who is mentioned herein as the manufacturer. A review of the maintenance records revealed the engine underwent a turbine assembly modification on April 11, 2002, during a turbine assembly overhaul. The modification was part of a commercial engine bulletin (CEB 1365R1), which allowed certain engines to be converted to obtain better performance "from the improved power turbine air flow characteristics." The conversion included a replacement of the 3rd and 4th stage nozzles and wheels. According to the maintenance records, the modified engine was installed on the accident helicopter on June 8, 2002, at an aircraft total time of 11,761.6 hours. On May 2, 2003, at an aircraft total time of 12,659.3 hours, the helicopter underwent an annual inspection, and the records were endorsed to the effect that the helicopter was in an airworthy condition. On June 6, 2003, at an aircraft total time of 12,752.3 hours, the helicopter underwent a 100-hour inspection in accordance with the manufacturer's 100-hour inspection guides. On the morning of the accident, the helicopter had accumulated a total of 12,804.6 hours.

The manufacturer's recommended time between overhaul for the modified turbine section was 1,750 hours.

The Allison 250-C20B is a two-shaft turboshaft engine with a combination compressor, which consists of a six-stage axial compressor attached to a one-stage centrifugal compressor. The engine incorporates a reverse-flow annular combustor, a two-stage high-pressure turbine (also referred to as the gas producer turbine or N1 turbine), and a two-stage low-pressure turbine (also referred to as the power turbine or N2 turbine). The gas path along the Allison 250 engine flows into the inlet, through the compressor's axial and centrifugal stages, into two external air transfer tubes and to the combustor, which is located at the very rear of the engine. The gases then turn 180 degrees toward the front of the engine and proceed through the two-stage compressor turbine (N1) and a two-stage power turbine (N2). Finally, the gases are directed out of the exhaust duct and upward through two exhaust outlets.

The gas producer (GP) turbine, consisting of turbine wheels and nozzles number 1 and number 2, drives the compressor section of the engine through an inner shaft, while the power turbine (PT), consisting of turbine wheels and nozzles number 3 and number 4, drives the power output gear (to the main rotor transmission) and the accessory gearbox through an outer shaft. The inner shaft rotates independently within the outer shaft.

Wreckage and impact information

A Federal Aviation Administration inspector and the operator examined the wreckage at the accident site and noted the 4th stage power turbine wheel shroud track was protruding through the turbine case. In addition, numerous 4th stage turbine wheel airfoils were found separated. Holes were punctured from the inside out in the turbine case and exhaust ducting.

The skids were spread, the pilot seat was collapsed, and the Plexiglass windscreen was melted. The tail boom was separated from the helicopter approximately 1 foot forward of the tail rotor. One of the main rotor blades was separated from the main rotor hub approximately 8 inches outboard of its hub, and was found approximately 100 yards from the main wreckage.

The helicopter was transported to Maui where the engine was removed from the airframe. According to the operator, two fittings were found loose during the engine removal; one was the fuel line upstream of the fuel nozzle (between the fuel control unit and the fuel nozzle), and the other was the oil supply line. The engine was shipped to Rolls-Royce Corporation, Indianapolis, Indiana, for further examination.

Tests and research

On July 14, 2003, the engine was examined by personnel from the FAA, the operator, the engine manufacturer, and overhaul facility. According to reports from the aforementioned personnel, the N1 and N2 turbine wheels would not rotate. The compressor case's plastic coating had melted during the postcrash fire, seizing the compressor section. Disassembly of the compressor section was not conducted. The upper and lower magnetic chip detectors were removed, revealing a light metallic fuzz. The combustion liner revealed heat and metal splatter damage.

The turbine section was removed from the accessory gearbox for disassembly. Upon disassembly, it was noted that the power turbine's (PT) number 3 wheel had all of its airfoils fractured, and the outer portions of the airfoils and shrouds were missing. The PT rotor was removed from the exhaust collector and it was noted that heavy scoring was present on the PT outer shaft surface. The PT number 3 nozzle displayed impact damage on the trailing edges of the airfoils, sections of which were missing. Heavy rub and impact damage was noted on the number 3 wheel side of the nozzle.

The PT number 4 nozzle displayed heavy impact damage on the airfoil leading edges. Sections of the airfoils' trailing edge were missing. The nozzle revealed heavy rub and impact damage on the PT number 3 and number 4 blade tracks. Review of the PT number 4 wheel revealed the outer portions of the blade airfoils and shrouds were fractured and missing over 225 degrees of the wheel circumference. The number 4 PT wheel also revealed impact damage on the airfoils' leading and trailing edges, and the remaining portion of shroud exhibited rub damage on the outer knife seals.

The gas producer turbine (GP) wheels rotated freely following their removal from the PT section and were no

Aircraft

Registration
N633WA
Reported as
Hughes 369D
Category
Helicopter
Serial number
1260042D
Airframe hours
12,804.6
Engine
Rolls-Royce 250-C20B, 425 horsepower, turbo shaft
Damage
Substantial damage
Fire
On-Ground
Flight
Other work use · Part 133
Registered owner
Windward Aviation Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 6, 2003 · 52.3 hours before
Departed
MKK · Molokai, HI

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
Serious
Certificates
Flight instructor, Commercial
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
March 7, 2003
Seat
Left
Flight hours
11,568 total · 8,055 in this make and model · 216 in the last 90 days · 85 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 14 knots, gusting 18
Visibility
10 statute miles
Temperature
81 °F, dew point 72 °F
Altimeter
29.98 inHg
Observed at
MKK, 4 nm away

Docket · 16

The files NTSB released with the investigation on October 26, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.